Guest post from Kristopher T. Kimmell, MD
Neurosurgical Resident, University of Rochester Medical Center
“There has to be this pioneer, the individual who has the courage, the ambition to overcome the obstacles that always develop when one tries to do something worthwhile, especially when it is new and different.”
- Alfred P. Sloan
The pioneer is frequently characterized by a number of strong personal traits: courageous, ambitious, visionary and irascible in the face of conventional wisdom. To forge a new path often requires tremendous diligence and patience against criticism, setbacks and failures. Indeed to forge a new field as audacious as neurological surgery requires a unique personality. Victor Horsley represents such a force of character that pioneered our specialty in its infancy. To this end, in honor of Neurosurgery Awareness Month, we are spotlighting him in our Faces of Neurosurgery’s Founders series.
Victor Horsley was not the first surgeon to perform a neurosurgical procedure. The practice of trephination — also known as making a burr hole, a surgical intervention where a hole is drilled into the skull — had been used for centuries. In the modern era, some general surgeons in England, particularly Sir William Macewen in Glasgow, had attempted some cranial procedures. The practice was still controversial and considered by some to be unethical. However, in 1886, at the young age of 29, Victor Horsley was the first appointed “brain surgeon” when he accepted his position at Queen Square in London, at what would become the National Hospital for Neurology and Neurosurgery. Based on the efforts of men such as Horsley, Queen Square would become one of the leading centers in the world in the study of neurologic diseases.
Despite his relative youth, at the age of 29 Horsley already had demonstrated his rare brilliance and energy. He had been appointed to the Fellowship of the Royal Society at the age of 27. Since his time in medical school at University College of London, he had conducted an extensive range of experiments elucidating the understanding of the nervous system. He used electric stimulation to localize functional areas of the brain in animals. He would eventually use this technique during surgical procedures in patients to identify so-called ‘eloquent’ regions of the human brain. Horsley was a true ‘physician-scientist’ who was very accomplished in the fields of anatomy and physiology. While at Queen Square he also oversaw the Brown Institute, which was the University College Hospital’s animal experiment laboratory.
Horsley’s surgical career was equally prolific. Shortly after his appointment to Queen Square, he operated on a man with intractable epilepsy from a traumatic injury. The operation was a great success. By the end of 1886, he had performed ten cranial procedures with only one death. By the turn of the century he had accumulated a series of 44 cranial procedures for tumors with a mortality rate of 10 percent; other practitioners in Europe had death rates near 50 percent. Horsley combined alacrity in the operating theater with delicate handling of nervous system structures to foster his success; this was a result of his tremendous knowledge and grasp of neuroanatomy from his years of experimental studies.
Horsley would pioneer a number surgical techniques and adjuncts during his tenure. In addition to performing the first surgeries for epilepsy, he was the first to develop a cranial approach to tumors of the pituitary gland. He was the first to perform surgery on a tumor of the spinal cord, with the patient making a marked recovery from paralysis. Horsley’s spinal surgeries were made easier by the use of instruments known as rongeurs, which were designed to remove safely hard bone immediately surrounding the spinal cord. The Horsley bone cutter, which bears his name, is still used by surgeons today. Horsley also invented a substance to abate bleeding from channels inside the bone. This mixture of beeswax, almond oil and salicylic acid is still used today and is known as bone wax. Horsley would also pioneer surgical treatments for trigeminal neuralgia or tic douloureux, a syndrome characterized by debilitating facial pain. He was the first to describe ligation of the carotid artery in the neck for the treatment of subarachnoid hemorrhage caused by a cerebral aneurysm. He also developed, with the help of Robert Henry Clark, a device that accurately localized regions inside the skull of monkeys. The so-called Horsley-Clark apparatus was one of the first attempts at stereotaxy and laid the groundwork for one of the most significant innovations in neurological surgery in the 20th Century.
In 1900, when Harvey Cushing, the father of neurological surgery in the United States, traveled to Europe to study with some of the giants of medicine and surgery, his first stop was to London to see Horsley. Despite the vast differences in their personalities and surgical styles, Cushing acknowledged Horsley as the true forebear of neurosurgery as a specialty.
Beyond his scientific and surgical exploits, Horsley was a visionary medical and social reformer. He was an avid supporter of women’s right to vote in England. He also spearheaded the reform of several medical organizations in England. Horseley had ambitions for political office when his medical career was over. However, at the start of World War I in Europe, Horsley left his practice to serve in medical corps of the British Army. He would eventually be stationed in modern-day Iraq, where he died of heat exhaustion at the young age of 59.
Neurosurgery is now a well-accepted and respected surgical specialty. A century of advances has made the range of disease processes treated by neurosurgeons vast, with ever decreasing morbidity and mortality. For today’s neurosurgeons, it’s hard to fathom that neurosurgery would not even exist without the prodigious and courageous careers of men like Victor Horsley. In honor of Neurosurgery Awareness Month we acknowledge this founder of neurosurgery and his indefatigable nature and pioneering spirit.